l . Severe, tearing/ripping/stabbing pain, either in the anterior or back of the chest(often the interscapular region)2. Diaphoresis3. Most are hypertensive, but some may be hypotensive4. Pulse or BP asymmetry between limbs5. Aortic regurgitation6. Neurologic manifestations (hemiplegia, hemianesthesia) due to obstruction ofcarotid artery

Abdominal Aortic Aneurysm (AAA)

l. Usually asymptomatic and discovered on either abdominal examination or a radiologicstudy done for another reason2. Sense of "fullness"3. Pain may or may not be present-if present, located in the hypogastrium andlower back and usually throbbing in character4. Pulsatile mass on abdominal examination

impending Abdominal Aortic Rupture

a. Sudden onset of severe pain in the back or lower abdomen, radiating to thegroin, buttocks, or legsb. Grey Turner's sign (ecchymoses on back and flanks) and Cullen's sign (ecchymosesaround umbilicus)

symptomsa. Intermittent claudicationCramping leg pain that is reliably reproduced by same walking distance (distanceis very constant and reproducible)• Pain is completely relieved by rest.b. Rest pain (continuous)• Usually felt over the distal metatarsals• Often prominent at night-awakens patient from sleep• Hanging the foot over side of bed or standing relieves pain-extra perfusionto ischemic areas due to gravity• Rest pain is always worrisome-suggests severe ischemia such that frankgangrene of involved limb may occur in the absence of intervention

symptomsl. Pain-acute onset. The patient can tell you precisely when and where it happened. Thepain is very severe, and the patient may have to sit down or may fall to the ground.2. Pallor3. Polar (cold)4. Paralysis5. Paresthesias6. Pulselessness (use Doppler to assess pulses)

Cholesterol Embolization Syndrome

• It is often triggered by a surgical or radiographic intervention (e.g., arteriogram), or bythrombolytic therapy.• It presents with small, discrete areas of tissue ischemia, resulting in blue/black toes,renal insufficiency, ancl!or abdominal pain or bleeding (the latter is due to intestinalhypoperfusion).

Mycotic Aneurysm

An aneurysm resulting from damage to the aortic wall secondary to infection• Blood cultures are positive in most cases.

Luetic Heart

complication of syphilitic aortitis, usually affecting men in theirfourth to fifth decade of life. Aneurysm of the aortic arch with retrograde extensionextends backward to cause aortic regurgitation and stenosis of aortic branches, mostcommonly the coronary arteries.

l. Swelling of the lower lega. When chronic, causes an aching or tightness feeling of the involved leg; oftenworse at the end of the dayb. Symptoms are worsened by periods of sitting or inactive standing.c. Leg elevation provides relief of symptoms (the opposite is true in arterialinsufficiency) .2. Chronic changes include:a. Skin changes• Skin becomes thin, atrophic, shiny, and cyanotic.• Brawny induration develops with chronicity.b. Venous ulcers• Usually located just above the medial malleolus• Often rapidly recur

Superficial Thrombophlebitis

l . Pain, tenderness, induration, and erythema along the course of the vein2. A tender cord may be palpated

l . Acute occlusion of an artery, usually caused by embolization. The commonfemoral artery is the most common site of occlusion. Less commonly, in situthrombosis is the cause.2. Sources of embolia. Heart (85%)• AFib is the most common cause of embolus from the heart.• Post-MI• Endocarditis• Myxomab. Aneurysmsc. Atheromatous plaque

Cholesterol Embolization Syndrome

• This syndrome is due to "showers" of cholesterol crystals originating from a proximalsource (e.g., atherosclerotic plaque), most commonly the abdominal aorta, iliacs, andfemoral arteries.• It is often triggered by a surgical or radiographic intervention (e.g., arteriogram), or bythrombolytic therapy.

Mycotic Aneurysm

An aneurysm resulting from damage to the aortic wall secondary to infection

Luetic Heart

A complication of syphilitic aortitis, usually affecting men in theirfourth to fifth decade of life. Aneurysm of the aortic arch with retrograde extensionextends backward to cause aortic regurgitation and stenosis of aortic branches, most commonly the coronary arteries.

a. History of DVT is the underlying cause in many cases (such a history might notbe documented).

Superficial Thrombophlebitis

l. Virchow's triad is again implicated (but pathophysiology not entirely clear)2. In upper extremities, usually occurs at the site of an IV infusion3. In lower extremities, usually associated with varicose veins (in the greater saphenoussystem)-secondary to static blood flow in these veins

DISEASES OF THE VASCULATURE TREATMENT AND MANAGEMENT

Question

Answer

Hypertensive Emergency

a. Reduce mean arterial pressure by 25% in l to 2 hours. The goal is not to immediatelyachieve normal BP, but to get the patient out of danger, then reduce BP graduallyb. If severe (diastolic pressure > 130) or if hypertensive encephalopathy is present,IV agents such as nitroprusside, labetalol, or nitroglycerin are appropriate.c. In patients who are in less immediate danger, oral agents are appropriate.Options include captopril, clonidine, labetalol, and diazoxide.2. Hypertensive urgencies: BP should be lowered within 24 hours using oral agents

l. Unruptured aneurysmsa. Management largely depends on size of aneurysm• If the aneurysm is >5 em in diameter or symptomatic, surgical resectionwith synthetic graft placement is recommended. (The infrarenal aorta isreplaced with a fabric tube.) The diameter of the normal adult infrarenalaorta is about 2 em.• The management of asymptomatic aneurysms <5 em is controversial. Periodicimaging is recommended to follow up growth. No "safe" size exists,however, and small AAAs can rupture.b. Other factors to consider are the patient's life expectancy (patient may be morelikely to die of other medical illnesses), and the risk of surgery

Peripheral Vascular Disease IPVD) (Chronic Arterial Insufficiency)

l. Conservative management for intermittent claudicationa. Stop smoking (the importance of this cannot be overemphasized) . Smoking islinked to progression of atherosclerosis and causes vasoconstriction (furtherdecreasing blood flow).b. Graduated exercise program: walk to point of claudication, rest, and then continuewalking for another cyclec. Foot care (especially important in diabetic patients)d. Atherosclerotic risk factor reduction (control of hyperlipidemia, HTN, weight,diabetes, and so on)e. Avoid extremes of temperature (especially extreme cold).f. Aspirin may be helpful.g. Trental (pentoxifylline) lowers blood viscosity (improving blood flow)-morestudies needed to establish its role in treatment.

Peripheral Vascular Disease (with rest pain)

• Surgical bypass grafting-this is the most common procedure and has a5-year patency rate of 70% (immediate success rate is 80% to 90%) .• Angioplasty-balloon dilatation

Acute Arterial Occlusion

a. Skeletal muscle can tolerate 6 hours of ischemia; perfusion should be reestablishedwithin this time frame.b. If paralysis or paresthesias are present, amputation is probably necessary.2. Immediately anticoagulate with IV heparin.3. Emergent surgical embolectomy is indicated via cutdown and Fogarty balloon.Bypass is reserved for embolectomy failure.4. Treat any complications such as compartment syndrome that may occur.

Cholesterol Embolization Syndrome

Treatment is supportive. Do not anticoagulate. Control BP. Amputation or surgicalresection is only needed in extreme cases

Mycotic Aneurysm

Treatment: IV antibiotics and surgical excision

Luetic Heart

Treatment: IV penicillin and surgical repair

Deep Venous Thrombosis (DVT)

l. Anticoagulationa. Prevents further propagation of the thrombusb. Heparin bolus followed by a constant infusion and titrated to maintain the PTTat 1 .5 to 2 times aPTTc. Start warfarin once the aPTT is therapeutic and continue for 3 to 6 months.Anticoagulate to INR at 2.0 to 3.0.d. Continue heparin until the INR has been therapeutic for 48 hours.

Deep Venous Thrombosis (with massive P E , patients who are hemodynamically unstable, those with evidence of right heart failure)

l. Before the development of ulcers, strict adherence to the following controls stasissequelae in most patients.a. Leg elevation: periods of leg elevation during the day and throughout the nightto a level above the heart.b. Avoiding long periods of sitting or standing.c. Heavy-weight elastic stockings (knee-length) are worn during waking hours